MEN’S HEALTH
Circumcision The debate of medical necessity BY DUONG TU, MD
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ircumcision, derived from the Latin circum- + caedere, meaning “to cut around,” is an apt description for the actual technique of removing the foreskin from around the glans, the head of the penis. It is the oldest documented elective surgical procedure performed in on humans. The technique of cutting around the glans has varied in the tools, anesthesia and timing. There are two broad categories of the modern method of circumcision: • Newborn circumcision using a nondisposable clamp such as the Mogen, Gomco or Plastibell under local anesthesia. • Circumcision in older infants, children and adults, which is performed under local or general anesthesia and usually is done as a surgical procedure.
Religious and social factors Circumcision originated in different parts of the world and dates back to ancient Egypt, 2400 BCE and biblical times. Circumcision throughout the ages may have been perpetuated in various cultures as a religious mark, status symbol or rite of initiation, as well as scorned as a social stigma, depending
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on the group or particular time in history. This deep connection to global spiritual history and cultural identity is one of the reasons why assessing its legitimacy in the modern world is not a straightforward proposition. One can see there is not just a medical side to this discourse, but also an emotional and spiritual one. Although the covenant of circumcision described in Genesis has been paramount to Jewish and Muslim identity, it is not a tenet of most Christian beliefs, with exceptions such as the Coptics. It is clear that circumcision was maintained in many Christian societies for puritanical reasons rather than religious beliefs. The “medicalization” of circumcision began in Victorian England, where infant circumcision was established due to inaccurate associations with sexual activity, especially masturbation, and venereal disease, as well as blindness, tuberculosis and psychiatric illness. Victorians erroneously believed the removal of the sensitive foreskin would serve as a deterrent to masturbation and promiscuity. However, the availability of circumcision remained limited, and it was reserved for the upper class. Similar parallels were made in the United States when circumcision miraculously cured a young boy’s paralysis in 1870. After that, routine circumcision spread like wildfire as surgical prophylaxis against all sorts of seemingly unrelated diseases. It became so prevalent in the United States that it morphed from a health measure to a symbol of American citizenship. According to a journal article from “Urology”: • “It became a mark of distinction, separating those who were born in the United States from those who were not, those who were clean and well bred from those who were poor, foreign, and unhygienic.” • Ironically, perhaps due to the wide scale availability of newborn circumcision in the US, even the poor and foreign now have access to the procedure. This prevalence withstood the test of time even when the historical rationales for circumcision were either forgotten or refuted. The issues of circumcision and its relationship to health promote ongoing debate regarding the role of circumcision, especially as societies and cultures evolve, leading toward re-evaluation and skepticism. This is healthy; when you close off the discussion, you stifle progress.
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JANUARY 2022 MINNESOTA PHYSICIAN
Economics From a financial perspective, newborn circumcision is roughly ten times less expensive than the cost of adolescent or adult circumcision, mainly due to the added cost of general anesthesia in the latter group. If that group opted for local anesthesia, the cost discrepancy would be greatly minimized. For example, a clinic in California that offers circumcision under local anesthesia over the full range of ages charges an estimated cost difference of $700 for clients age one and older. These clinics provide the service to a population not typically covered by health insurance programs (ages greater than 1), albeit sometimes at a premium, and demonstrate the actual feasibility of circumcision under local anesthesia past the newborn phase.
